Fungal nails are a plague that you can't get rid of. They can cause your nails to become yellow, brown, and/or black and have you thinking twice before you hit the beach with sandals when it finally warms up. I would like to tell you about my approach to a fungal nail infection.

When a patient walks into the podiatry office with a high suspicion of fungal infection, the first thing to do is take a biopsy. This generally involves cutting away some nail pieces to send to the pathologist. The pathologist will inspect the nail tissue for signs of infection and use a special stain to visualize the fungal organisms. After the biopsy I will trim the nail and clean it up and send the patient home to return in about a week.

If, and when the pathology report comes back positive for fungus, it’s time to consider treatment options. Let's assume we have a relatively healthy patient that wants to be able to wear sandals. There are basically two options that I present the patient with. If only one nail is infected (most commonly the big toe) then I present the patient with the option to remove the nail completely. This is a simple 5-10 minute procedure that requires anesthesia of the toe and some sterile instrumentation to remove the entire nail. The patient will be put on an oral antifungal agent to ensure no fungus survives and the nail will grow back clean and normal. This treatment is aggressive but offers the greatest chance of full nail recovery.

The second option is to leave the infected nail intact and try to treat the infection with lasers, creams, or oral antifungal agents. Lasers and topical creams can work to kill the organism within the nail but should be stacked with an oral antifungal agent that works to kill the fungal organisms on a systemic level. This option can also result in a clean and normal looking nail in some cases. If the fungal infection has been present for years or even decades then a full recovery is very difficult or impossible to achieve.

Oral antifungal agents such as terbinafine have been the gold standard treatment for fungal nails and every treatment regimen should include this medication. Even with this medication, there are some nails that will never return to normal. If you have nails that have recently started to change color or become brittle and oddly shaped then you may have a fungal infection and you have the best chance for recovery if you treat it immediately. Remember, your local podiatrist sees patients with fungal infections on a daily basis.